Friday, April 29, 2016

(LML) Economics of leprosy control

Leprosy Mailing List – April 29,  2016

Ref.:  (LML)  Economics of leprosy control

From:  Marco Andrey Cipriani Frade, Ribeirão Preto, Brazil



Dear Pieter,



I would like to give my congratulations to Joel Almeida (LML, April 18, 2016) by the nice words about - How can we show and measure the zero disability as our goal?


Additionally, I have some other questions to stimulate reflections about leprosy:

-       What are we doing to change properly the leprosy indexes? 

-       Why are many important and scientific people searching to achieve a prevalence index with no worry about incidence? Even with disability index?


Nowadays, I and other colleagues have the impression that there are more people seating in their offices working to modify the leprosy data bank than working to look for and find new cases outside.


Which is our goal in fact? Protecting people against leprosy and the disabilities or just to reach good indexes to say "there is no leprosy here" and to close leprosy services with no considering that leprosy is a chronic disease having the humans as a perfect reservoir for M. leprae? The professionals are not trained properly at school to recognize early leprosy signs, the society heard more about "there is no leprosy anymore" than about leprosy signs and symptoms. So, our goal should be always training and information, but it isn't good for the majority of governments and politics unfortunately. 


Best regards,



Marco Andrey 


Prof. Dr. Marco Andrey Cipriani Frade - Professor Associado (Livre Docente)

Coordenador da Divisão de Dermatologia // Atual Presidente Soc. Brasileira Hansenologia (2015/17)

Coordenador Residência Médica de Dermatologia HCFMRP-USP

Coordenador Centro de Referência em Dermatologia Sanitária - Hanseníase - HCFMRP-USP


Divisão de Dermatologia - Departamento de Clínica Médica

Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo

Av. Bandeirantes, 3900 - Monte Alegre - Ribeirão Preto -SP - Brasil

CEP: 14.049.900 - Tel: 55-16-36022441 (Sala) - 36022447 (Sec.) - FAX: 55-16-36021522


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Monday, April 18, 2016

(LML) Economics of leprosy control

Leprosy Mailing List – April 18 ,  2016

Ref.:  (LML)  Economics of leprosy control

From:  Joel Almeida, Mumbai and London

Dear Pieter,


The Government of India is resuming more vigorous efforts to protect its people against M. leprae. 


House-to-house case-finding surveys have been done in 50 districts with the highest incidence rate of leprosy.  More districts are to be included.  Such surveys, provided they are backed by skin smear examination and experienced paramedical workers, have the potential to detect polar lepromatous patients who still require MDT. Many polar lepromatous patients, after being released from MDT, migrate to urban areas to boost their income and escape from local ostracism. The others can still be found by house-to-house surveys in high-incidence districts.


Unprotected polar lepromatous patients (whether before treatment or after release from MDT) are the no. 1 source of M. leprae, according to current microbiological knowledge. Denying polar lepromatous patients MDT ensures a world full of M. leprae, not a world free from leprosy. Such lack of protection is cruel to the patients, but extremely favourable to M. leprae. As long as we deny polar lepromatous patients prolonged protection by MDT, even mass chemoprophylaxis is likely to be futile.


House-to-house case-finding uncovers many self-healing forms of leprosy too. In these individuals, the signs of leprosy indicate a successful immune response rather than bacterial proliferation. The more frequent and more intensive the surveys, the greater the chance of finding transient, self-healing cases.  This accounts for the boost in incidence rate after the introduction of MDT, from about 500,000 cases a year in 1985, to about 800,000 cases a year in 2000. The subsequent progressive suppression of case-finding accounts for the drop in incidence rate to under 250,000 cases a year. Self-healing cases disappear from the incidence rate if surveys are suppressed. Therefore the new case detection rate is unreliable as an indicator of the trend in incidence rate. It can be doubled or halved at will, by starting or stopping case-finding surveys.


Visible deformity, by contrast, is not transient.  The trend in the incidence rate of new cases with visible deformity, more reliably than the new case detection rate, indicates the trend in incidence rate of leprosy. The incidence rate of new cases with visible deformity has almost doubled in India since 2005-6, according to official Indian reports. This strongly suggests a near-doubling in the incidence rate of progressive forms of leprosy, in India, since 2005-6.


The Indian government has been pressed by civil society to wage a more intensive battle against M. leprae. A concerned citizen even took the government to the Supreme Court. The petition requested sufficient staffing for the leprosy programme. The programme had been battered by premature self-congratulation, loose claims about cost-effectiveness, and needless elimination of leprosy services. People affected by leprosy had inadequate services to begin with, and this needless assault on leprosy services left them completely vulnerable to visible deformity.


Cost-effectiveness is relevant mainly after effectiveness is well established, and after interventions are scaled up.  Economies of scale transform costs. Our first responsibility is to protect people from disability. We are not in the business of saving money, but of saving people's limbs and eyes.  That's why demonstration projects of highly effective interventions are so important.


The Governor of the Reserve Bank of India agrees with this viewpoint, which I had the good fortune to discuss with him in person. Spending on effective health programmes is investment, not expenditure.  Deformed citizens lose not only their quality of life, but also a stream of future income, as well as costing the taxpayer a considerable sum for rehabilitation. It is better, for the economy, to invest in effective interventions, than to allow citizens to suffer deformity.


Whenever we enquire about the cost-effectiveness or cost-benefit of leprosy services, we need to compare it to the cost-benefit of armaments etc. Taxpayers fund a variety of activities which do little to save human beings from death or disability. Let not a blinkered view of cost-benefit stand in the way of protecting human beings.


We need to enlarge our vision beyond the premature, and temporary, self-congratulation that has so blighted leprosy work and financing.  We need to devise demonstration projects where cost is no object.  We need to demonstrate effectiveness first: how to save the limbs and eyes of human beings.  Then we can analyse and streamline costs.  The flow of financing, from taxpayers as well as noble-minded donors, will increase to match the opportunity of transforming human lives.


This happened in TB, where the global budget went from about a hundred million dollars per year in 1995 to several billion dollars per year by 2005.  It would be good if we started batting more vigorously for the human beings at risk from leprosy. Then we can truly provide people with the leprosy services which will protect them against visible deformity, and perhaps even make a dent on the incidence rate of progressive forms of leprosy.


A positive sign is that we now speak of zero disability as our target. This is crystal clear and rational. Let's demonstrate how we achieve zero disability in projects, then scale it up. We need to develop systems that are demonstrably effective in the field, then funding will start to flow more readily.






Joel Almeida

LML - S Deepak, B Naafs, S Noto and P Schreuder

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Thursday, April 14, 2016

(LML) WHO Goodwill Ambassador's Newsletter No.78 Issue

Leprosy Mailing List – April 14,  2016

Ref.: (LML)   WHO Goodwill Ambassador's Newsletter No.78 Issue

From:  Hiroe Soyagimi, Tokyo, Japan


Dear Dr Schreuder and Friends,


Warm greetings from Sasakawa Memorial Health Foundation in Tokyo. 

We have uploaded our latest edition of  "WHO Goodwill Ambassador's Newsletter No.78 Issue" to our website. 

Please visit to obtain electronic version of this issue. 

In this issue we feature articles about ...

Message: Tapping the Power of Youth

Global Appeal 2016:    Looking to the Young Generation

                                    Nothing about Us, Without Us

                                    Youthful Perspectices

                                    Getting people to 'Think Leprosy Now'


News:  Miyazaki's Awakening

From the Editors:  Human Evolution


We hope you enjoy our latest Newsletter!


Hiroe Soyagimi

Sasakawa Memorial Health Foundation


Sasakawa Memorial Health Foundation




visit our website at


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Tuesday, April 12, 2016

(LML) The Diagnosis of Leprosy

Leprosy Mailing List – April 12 ,  2016

Ref.:   (LML) The Diagnosis of Leprosy

From:  Grace Warren, Sidney, Australia

Dear Pieter,

I have been interested following all the suggestions re  upcoming conference,  and the variations in statistics - partly  achieved by literally applying  the WHO definition as it appears many years ago.,  The Indian statistics of the numbers of children especially who have leprosy but it is not officially recognised so their official statistics look very good.

However, many times I have written about the numbers who never do have an anaesethetic patch as so many East Asian patients have infiltrated skin but no definite patch and no loss of pain sensation yet in the old days we could do slit skin smears that confirmed the diagnosis.   Now very few out clinics have the knowledge and ability to do the slit skin smears.

But I feel more and more that one very big problem that I am sure WHO could do something about is the teaching of leprosy in Medical Colleges.,

One year I lectured in all the medical colleges in one of the big countries accepted as being endemic. I was informed in most, that it was the first time that that college had had a lecture on leprosy!!!!!  What we do not know we never see and what we need is to ensure that the possibility of leprosy comes to the mind of doctors treating , especially children in endemic countries. Lepromatous leprosy is so easy hidden in the early days when it is easily passed on to the children.   After one lecture to the medical Practitioners the Chairman who happened to be the head of the local group said “Thank you for that. I hate to think how many I have missed over the years!” What a confession - but many doctors in these countries have no thought of leprosy as a diagnosis as they have not been taught to consider it !.

I do hope the teaching will become more widespread - and if  the definition could be varied, that could help. This letter  from Ben gives a few minor variations - but  we really need a few more possibilities to make people think  of Leprosy as a possible diagnosis.


Best regards,


Grace  Warren.  (Previously advisor for the leprosy Mission in Asia 1975-1995)


LML - S Deepak, B Naafs, S Noto and P Schreuder

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(LML) Recent Articles on Leprous Neuropathy and Surgical Nerve Decompression

Leprosy Mailing List – April 12,  2016
Ref.: (LML) Recent Articles on Leprous Neuropathy and Surgical Nerve Decompression
From:  Eric Lee Wan, Baltimore, USA

Dear Dr. Schreuder,

Thank you for managing the LML. I would like to take this opportunity to share with the community two recent publications from our group. They are attached and can be shared with LML readers.

They are cited as:

- Multiple Crush Concept Applied to Multiple Nerves in Leprous Neuropathy. Dellon AL. Clin Podiatr Med Surg. 2016 Apr;33(2):203-17.

- Treatment of Peripheral Neuropathy in Leprosy: The Case for Nerve Decompression Wan EL, Rivadeneira AF, Martinez Jouvin R, Dellon AL. Plast Reconstr Surg Glob Open. 2016 Mar;4:e637.

With warm regards,

Eric Lee Wan, BS

Research Fellow
Dellon Institutes for Peripheral Nerve Surgery &
Department of Plastic and Reconstructive Surgery,
Johns Hopkins University School of Medicine

USA Cell: 
+1 (240) 899 1181
Ecuador Cell: 
+593 098-877-5430
Colombia Cell: +57
(313) 780-6653
Skype: ericleewan

Patient information:
Personal and others: or

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Tuesday, April 5, 2016

(LML) Monthly overview of publications on leprosy and related issues - April 2016

Leprosy Mailing List �C April 5,  2016

Ref.:   (LML)  Monthly overview of publications on leprosy and related issues - April 2016

From:  Jiske Erlings, Amsterdam, the Netherlands


Dear Pieter,



Greetings from Infolep!
Below you will find a selection of recent publications on leprosy and related subjects. Feel free to contact me to receive the full text versions if a link to the full text is not included. Keep sending us your publications on leprosy or material on leprosy in your language to include in the portal.

With kind regards,
Jiske Erlings
INFOLEP Information specialist



New publications



Leprosy incidence, characterization of cases and correlation with household and cases variables of the Brazilian states in  2010. Castro SS, Santos JP, Abreu GB, Oliveira VR, Fernandes LF. in: An Bras Dermatol. 2016 Feb;91(1):28-33.
Full text:

Evaluation of National Leprosy Eradication Program after Integration into General Health System in Rajkot District, Gujarat from 2003 to 2014. Chudasama RK, Lakkad SG, Patel UV, Sheth A, Thakkar D, Rangoonwala M. in: Indian J Dermatol. 2016 Jan-Feb;61(1):57-62.

Field-friendly test for monitoring multiple immune response markers during onset and treatment of exacerbated immunity in leprosy. Corstjens PL, van Hooij A, Tjon Kon Fat EM, van den Eeden SJ, Wilson L, Geluk A. in: Clin Vaccine Immunol. 2016 Mar 30.

Multiple Crush Concept Applied to Multiple Nerves in Leprous Neuropathy. Dellon AL. in: Clin Podiatr Med Surg. 2016 Apr;33(2):203-17.

Hansen's disease in association with immune reconstitution inflammatory syndrome. George A, Vidyadharan S. in: Indian Dermatol Online J. 2016 Jan-Feb;7(1):29-31.
Full text:

Childhood Leprosy in an Endemic Area of Central India.  Gitte SV, Sabat RN, Kamble KM. in: Indian Pediatr. 2016 Mar 8;53(3):221-4.
Full text:

Factors Contributing to the Delay in Diagnosis and Continued Transmission of Leprosy in Brazil - An Explorative, Quantitative, Questionnaire Based Study.
Henry M, GalAn N, Teasdale K, Prado R, Amar H, Rays MS, Roberts L, Siqueira P, de Wildt G, Virmond M, Das PK. in: PLoS Negl Trop Dis. 2016 Mar 15;10(3):e0004542.
Full text:

Some case reports which suggest correlation between biologics and leprosy, Mini-symposium on problems on leprosy. Ishida Y. in: Nihon Hansenbyo Gakkai Zasshi. 2016 Jan;84(3):133-7. Japanese

Hearing loss in leprosarium: Current status. Kosugiyama R, Kasai N, Etani T, Oshima A. in: Nihon Hansenbyo Gakkai Zasshi. 2016 Jan;84(3):125-31. Japanese.

Bayesian model, ecological factors & transmission of leprosy in an endemic area of South India. Joshua V, Mehendale S, Gupte MD. in:  Indian J Med Res. 2016 Jan;143(1):104-6.
Full text:

Serum uric acid levels during leprosy reaction episodes. Morato-Conceicao YT, Alves-Junior ER, Arruda TA, Lopes JC, Fontes CJ. in: PeerJ. 2016 Mar 14;4:e1799.
Full text online:

The originality and creativity of leprosy sequelae patients in regard to dental care. Nakagawa M, Shimizu A. in: Nihon Hansenbyo Gakkai Zasshi. 2016 Jan;84(3): 119-24. Japanese. PubMed PMID: 27008825.

Hertoghe sign: an hallmark of lepromatous leprosy. Parrino D, Di Bella S. in: QJM. 2016 Mar 29.
Full text:

People like me don't make things like that?: Participatory video as a method for reducing leprosy-related stigma. Peters RMH, Zweekhorst MBM, van Brakel WH, Bunders JFG, Irwanto. in: Global Public Health. 2016.

Peripheral hypertrophic neuropathy due to leprosy: Ultrasound and MR imaging findings. Pottecher P, Flageul B, Sibileau E, Laredo JD, Bousson V. in: Diagn Interv Imaging. 2016 Mar 2.

Pure neuritic leprosy: Current status and relevance. Rao PN, Suneetha S. in: Indian J Dermatol Venereol Leprol. 2016 Mar 30.
Full text:

Bosch and Bruegel. Disability in sixteenth-century art. Rutecki GW. in: Pharos Alpha Omega Alpha Honor Med Soc. 2016 Winter;79(1):44-54. PubMed PMID: 26930764.

Leprosy Reactions Show Increased Th17 Cell Activity and Reduced FOXP3+ Tregs with Concomitant Decrease in TGF-β and Increase in IL-6. Saini C, Siddiqui A, Ramesh V, Nath I. in: PLoS Negl Trop Dis. 2016 Apr 1;10(4):e0004592.
Full text:

Pain and quality of life in leprosy patients in an endemic area of Northeast Brazil: a cross-sectional study. Santos VS, Santana JC, Castro FD, Oliveira LS, Santana JC, Feitosa VL, Gurgel RQ, Cuevas LE. in: Infect Dis Poverty. 2016 Mar 7;5(1):18.
Full text:

Prevalence of Disability and Associated Factors among Registered Leprosy Patients in All Africa Tb and Leprosy Rehabilitation and Training Centre (ALERT), Addis Ababa, Ethiopia. Shumet T, Demissie M, Bekele Y. in: Ethiop J Health Sci. 2015 Oct;25(4):313-20.
Full text:



Journals & Newsletters



Disability, CBR & Inclusive Development:
Leprosy Review:

Plos Neglegted Tropical Diseases:
Revista de Leprología:
WHO Goodwill Ambassador's Newsletter for the elimination of leprosy:




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(LML) The Diagnosis of Leprosy

Leprosy Mailing List – April 5,  2016

Ref.:   (LML) The Diagnosis of Leprosy

From:  Ben Naafs, Salvatore Noto, Pieter Schreuder

Dear LML readers,

In response to the ongoing discussion about the diagnosis and classification of leprosy on LML we would like to emphasis that the 3 major criteria for the diagnosis of leprosy are already known for over 100 years. They are:

1) Loss of sensation to touch in a skin lesion.
This criterion can be replaced by loss of sensation for heat and cold, positive histamine test, absence of sweat after heat or running, or a difference with normal skin after injection of pilocarpine. This is all in the hypo-pigmented or erythematous skin patch.

2) Enlarged peripheral nerves on palpation
It can be replaced by ultrasound determination of the size of the nerves or by nerve function loss. Trauma and hereditary motor or sensory neuropathy have to be excluded.   Nerve conduction velocity studies may be of help.

3) Positive skin smear.
It can be replaced by skin or nerve biopsy with AFB's. Be sure that the destaining of the AFB's is for M.leprae and not for M.tuberculosis! This criterion can be also replaced by positive antiPGL1; and PCR or NASBA positive for M.leprae.

Two out of these three criteria confirm the diagnosis of leprosy. This does not mean that in the field an experienced health worker may not provisionally diagnose a patient on one criterion and start treatment. Because early treatment of leprosy prevents live long disability. It is a balance, this against the side effects of drugs and the stigma related to the diagnosis.

Early lepromatous, early borderline-lepromatous, early tuberculoid and indeterminate leprosy deserve special notes. Early lepromatous and early borderline-lepromatous often do not show loss of sensation in the skin lesion (or in the infiltrated skin) and may not have enlarged nerves or detectable nerve damage. Indeterminate leprosy does not show peripheral nerve involvement, and this can also be the case of early tuberculoid  leprosy.

Finally, in the field, in endemic areas with no available laboratory facilities, the experienced leprosy worker has to rely on clinical skills only.  That is: aspects of the lesions (borders, distribution, signs of inflammation; redness infiltration, etc.), detection of loss of sensation, neuritis, sequelae of nerve function loss and palpation of peripheral nerve trunks.

In cases of doubt, it is wise to re-examine the patient after 3 months; in general leprosy develops slowly.

Always consider the balance; side effects of treatment and stigma against damage to the patient by not treating.

With regards,

Ben Naafs, Salvatore Noto and Pieter Schreuder

LML - S Deepak, B Naafs, S Noto and P Schreuder

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